NOW OR NEVER - Royal Pharmaceutical Society

NOW OR NEVER: shaping pharmacy for the future

Judith smith catherine picton mark Dayan

executive summary: the repor t of the Commission on future models of care delivered through pharmacy

Now or Never: shapiNg pharmacy for the future 3

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BackgrounD

recent nhs reforms, along with an unprecedented era of economic, demographic and technological change, present both challenges and opportunities for the pharmacy profession. there are many visions for pharmacy in circulation, and many new models of practice have been developed by pharmacists across england. however, as yet there has been little to knit these together in a coherent narrative for the profession’s future role in the english nhs.

With this in mind, the royal pharmaceutical society set up a commission on future models of care, chaired by Dr Judith smith, Director of policy at the nuffield trust. the commission has brought together expertise from across pharmacy, the wider health care sector, and patients and the public to develop practical ideas about how future models of care can be delivered through pharmacy. the commission has now completed its work, and this paper provides a summary of the key findings and recommendations from its work.

4 Now or Never: shapiNg pharmacy for the future

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key points

n the traditional model of community pharmacy will be challenged as economic austerity in the nhs, a crowded market of local pharmacies, increasing use of technicians and automated technology to undertake dispensing, and the use of online and e-prescribing bear down on community pharmacies’ income and drive change. a broader role for pharmacists as caregivers will be central to securing the future of community pharmacy.

n the nhs is engaged in an urgent search for ways to provide better standards of care in the face of unprecedented pressure on budgets, and justifiably intense scrutiny of quality. only by adapting to the needs of patients with long-term conditions and preventable illnesses can this be achieved. pharmacists have a vital role in helping the nhs make the shift from acute to integrated care, and fulfilling the pressing need to do more for less.

n some patients, carers and members of the public have access to a broader range of services and care from pharmacy than the traditional dispensing and supply of medicines. pharmacists increasingly provide services that help people stay well and use their medicines to best effect. however, the pace of change remains slow, and financial and structural incentives are not sufficiently aligned to support it.

n pharmacists are working more closely with patients and healthcare colleagues in hospitals, outreach teams, patients’ homes, residential care, hospices, and general practice, as well as in community pharmacies. they are helping patients to manage their own conditions, providing health checks, supporting best use of medicines, and detecting early deterioration in patients’ conditions.

n high street presence and long opening hours mean that community pharmacy has the potential to play a crucial role in new models of out-of-hours primary and urgent care. access by pharmacists to integrated patient records will be a key enabler of this, as will the active engagement of pharmacists in local primary care federations, networks and super-partnerships.

n Despite its potential, pharmacy – and particularly community pharmacy – is marginalised in the health and social care system at both local and national level. it is seen by others as a rather insular profession, busy with its own concerns and missing out on debates and decisions in other health and social care organisations and the wider world of health policy.

n alongside this, there is insufficient public awareness of the range of services pharmacists can offer. there is a pressing need to de-mystify pharmacy so that patients, the public and the rest of the health service understand the extent of the role that pharmacists do and can have in providing direct care.

n focused, outward-looking local and national leadership of pharmacy will be needed to change this. Leaders within pharmacy need to work with national and local commissioners and providers of other care services to ensure a shift in the balance of funding, contracts and service provision away from dispensing and supply, towards using the professional expertise of pharmacists to enable people to get the most from their medicines and stay healthy.

n to enable such a shift, there will be a need for a significant rethink of the models of care through which pharmacy is delivered, as a prerequisite to developing new approaches to contracting and funding that include: the possibility of specific contracts with groups of pharmacists to deliver patient services; and population-based contracts for new larger primary care organisations that include pharmacists in their membership along with gps, nurses and others.


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pharmacy can offer more

Keeping people healthy, meeting common needsnew models of care which put pharmacy at the forefront of keeping people healthy and meeting common health needs have been pioneered and proven across england and in other countries. they provide important examples of good practice, and evidence that pharmacy can help the health and social care system achieve more for less at a time of economic austerity and rising demand.

the commission saw numerous examples of innovative practice delivering proven success. one example is the healthy Living pharmacy scheme where pharmacists and their teams use their regular contact with the public to deliver services including smoking cessation, sexual health advice, and guidance on lifestyle changes to combat obesity. the programme has already demonstrated clear improvements in outcomes, such as smoking cessation for patients accessing these services.

pharmacy has shown that it can do more in treating common, self-limiting ailments. By becoming the default first point of contact for patients as part of integrated local urgent and out-of-hours services, pharmacists could take pressure off general practice, using their location on local high streets to give greater convenience for patients. evidence from common ailments schemes commissioned across the united kingdom shows that pharmacists can provide a suitable alternative to gp consultations for these conditions and that the number of gp consultations tends to decline as pharmacy expands its role.

supporting people with long-term conditions and helping them get the most from medicines effective care for people with multiple long-term conditions is an increasingly pressing priority for the nhs. medicines are generally the backbone of treatment and pharmacists have a critical role in helping patients manage their treatment and stay well through best use of medicines, for example by using regular consultations in local pharmacies or gp surgeries to support people with asthma to use their inhalers and other medications to best effect.

in some areas hospital pharmacists – as well as forming a core part of clinical teams whilst patients are in hospitals – are now members of outreach teams that help co-ordinate and deliver domiciliary support for the frail elderly or other patients with complex needs to ensure that once they are discharged from hospital they avoid readmission due to sub-optimal medicines use.

the need to support best use of medicines has been recognised nationally through the consensus on ‘medicines optimisation’ with guidelines drawn up by the royal pharmaceutical society and endorsed by nhs england, the royal college of general practitioners and others. the nationally commissioned medicines use reviews and new medicines service provide a base from which to develop other direct patient services.

primary care pharmacists based in clinical commissioning groups or commissioning support units often take the lead in integrating pharmacists into care pathways and multidisciplinary teams. examples submitted to this commission included pharmacists working with multidisciplinary teams to review gps’ patients identified as at high risk of admission to hospital because of their medicines, and pharmacists forming part of teams commissioned to provide on-going healthcare and advice to residents and staff in local care homes. in recognition of successes in this area, the nhs alliance recently called for the employment or attachment of medicines optimisation pharmacists to all general practices.


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the future WiLL DemanD a BroaDer roLe for pharmacy

the Nhs faces unprecedented challengesas the government looks to reduce the uk’s fiscal deficit, the nhs is likely to face an effectively flat budget up to 2021/22, with little scope for spending increases as other government departments bear deep cuts. yet rapidly rising demand for healthcare, which has driven consistent spending increases in the past, will continue and the resulting upward pressure on costs of around 4% per year means that the health service must find savings of the same amount to continue providing comprehensive care. these proposed savings are unprecedented in nhs history, and far beyond anything seen to date in health productivity growth.

funding for additional services delivered through pharmacy will therefore have to be found from within existing resources, entailing either a shift within the global sum spent on community pharmacy services (from dispensing and supply towards the provision of patient services), a redistribution of funds currently spent in other parts of the nhs, such as general practice and community health services, or both of these.

the typical nhs patient now suffers from one or more long-term conditions such as asthma, diabetes, and dementia. this reality demands more emphasis on joint work across services, helping people to manage their conditions, and providing treatment and support for self-management outside hospital. achieving these shifts in capacity – a task in which pharmacy must play a major role – will be essential to the nhs conserving funding by reducing and preventing the need for care.

meanwhile, quality of and access to services are under close scrutiny. in the wake of the appalling lapses at mid staffordshire foundation trust, hospital trusts, health and social care regulators and the government are implementing a range of challenging reforms to guarantee effectiveness, safety and dignity for patients. the need to maintain access to urgent and out-of-hours care remains critical: policy makers increasingly look to primary care, including community pharmacy, to play a broader role.

community pharmacy under increasing pressurethe traditional community pharmacy business model of reliance on dispensing (including profits from purchasing drugs for the nhs) and supply faces increasing financial challenges, set to continue for the foreseeable future. the funding situation in the nhs has already resulted in a flat total budget for pharmaceutical services since 2010 after a period of rapid growth. prices and policies for dispensing and purchasing on behalf of the nhs will continue to reflect this. yet like other primarily nhs-funded services, flat budgets for these services co-exist with steadily rising demand: prescription volume continues to rise at around 4% per year. the gap between demands for more output and the flat-lining of funding is therefore likely to squeeze profits and salaries.

in the medium to longer term, technology will prove increasingly capable of taking over significant parts of dispensing and supply roles. hospital pharmacy, and community pharmacy in some other countries, has seen the use of robotics (supported by changes to skill-mix) take on much of the dispensing workload. use of the internet to supply pharmaceuticals is also likely to expand rapidly.

in a market which has become increasingly crowded, a recent report by at kearney estimated that these challenges would reduce the profits of the average community pharmacy by 33%, resulting in the closure of 7.5% of all england’s community pharmacies by 2016. these pressures will continue and intensify past this date, and community pharmacy will face significant challenges where it does not broaden its offer (and hence its base of funding) by providing a wider range of services to patients and commissioners.


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What must Be Done

winning a seat at the tablepharmacists need to become first and foremost providers of patient care, rather than dispensers and suppliers of medicines. this is central to securing a future in which the profession can flourish and thrive as a critical part of the answer to the urgent search for efficiency and access in the nhs.

this commission was struck by how far pharmacy is marginalised within the health, social care and public health systems in england. the public seem to be largely unaware of the broader range of services they should be expecting to be offered proactively in their community pharmacies. other professions, and national and local bodies in the nhs, told us that they did not understand the potential range of services that pharmacy argues it can provide, nor see pharmacy engaging in a sustained and vocal manner with wider nhs financial and service challenges and opportunities.

the commission also noted that pharmacy is often absent from key health policy and management circles and discussions, and where it is present it lacks standing and influence, despite being the third largest health profession. for this to change, pharmacy must advocate for itself, building and disseminating a powerful narrative about the services it can deliver and doing all it can to put these services into practice, influence commissioners, and demonstrate to patients and the public what is possible.

the royal pharmaceutical society and other professional bodies must jointly shape a narrative of pharmacists as providers of care, and advocate for this at every level. a forum of leading innovative practitioners should be established, through which new models of care can be shared, supported and promoted. national and local leadership must learn from and spread the can-do attitude that this commission heard from leading local practitioners. pharmacists should be bidding for contracts from the nhs and local government wherever possible, developing new services, and making their case to commissioners on equal terms with other professions.

Bold commissioning of pharmacy services there is a need to ensure that contractual and commissioning structures support new models of care involving pharmacy, and align them to the best interests of patients and populations.

pharmacy should not look solely to renegotiation of the national community pharmacy contract as a prerequisite for providing more services. as new local outcomes-based contracts that cover a wider range of primary and community health services are developed for primary care and general practice (as seems increasingly likely), the pharmacy profession must advocate clearly to form part of such arrangements. pharmacists could deliver medicines management and other services as part of primary care networks or federations, with registered populations and accountability for health outcomes. they could do this either by being part of a local multidisciplinary network or through holding sub-contracts to general practice organisations.

pharmacists could do more to prepare for the challenge of bidding for contracts and expanding services by considering forming their own federations, provider networks or ‘chambers’ (a group of professionals sharing support services in much the same way as barristers do), learning from how gps have been organising themselves to run a wider range of services under contract to the nhs. pooling resources in this way could create more flexibility, greater capacity bidding for contracts, and new opportunities to learn from one another.

commissioners, meanwhile, must be bold in exploring new roles for pharmacy. at a local level, clinical commissioning groups and local authorities should recognise that pharmacists are often an under-used service with high street presence, strong community connections and long opening hours, and should consider how they might deliver better services for less money by using pharmacists to take on roles within urgent care, common ailments, and long-term conditions services.

at a national level nhs england should use its position as the commissioner of pharmacy services to encourage a shift in funding from dispensing and supply, towards keeping people healthy and getting the most from medicines.


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hoW to make it happen

the commission found widespread support for the idea of pharmacy extending its role and focusing more on the provision of services to patients and the public. analysis by pharmacy of what this might look like has not been in short supply over the years, the direction of travel is clear, and yet progress in making change remains far too slow.

Drawing on submissions to the commission, published research, and conversations with pharmacists and others in the broader health and care system, we set out here what needs to be done to enable the shift towards a greater role for pharmacy in delivering patient care. the commission has developed recommendations about the changes needed if pharmacy is to flourish in the future and offer the population the range of services it should rightly expect:

recommendations to pharmacists n pharmacists and their employers must recognise the

imperative to shift their focus away from dispensing and supply of medicines towards providing a broader range of services. they must see their ultimate goal as helping people get the most from their medicines and keeping them healthy.

n pharmacists and employers should not wait for national solutions but should drive change at a local level, proving their case for service provision to clinical commissioning groups, local area teams and local government commissioners by making and winning tenders.

n pharmacists must appreciate the financial constraint and intense scrutiny of quality facing the nhs. they must show how they can meet patient needs better and more efficiently than many existing providers. this will have to be done by developing new services through reallocation of existing funding: there will be no new money.

n pharmacists must collaborate with each other across community, social, secondary and tertiary care and with other healthcare professions, to develop models of care which enable commissioners to deliver integrated patient pathways, and ensure patients have consistent access to support with medicines use as they move between care settings.

n pharmacists should develop networks or professional ‘chambers’ to pool the expertise, influence and managerial capacity they will need to develop proposals, deliver larger scale services, and work with the increasingly influential federations, networks and super-partnerships in general practice.


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recommendations to Nhs england, public health england, and the Department of health

n nhs england and public health england should work with the royal pharmaceutical society and other leaders of the profession to drive a consistent vision of the future of pharmacy.

n nhs england and public health england must include pharmacy in plans for the future of out-of-hours and urgent care, public health, and the management of long-term conditions. they will likely need the help of pharmacy leaders here, and should consider seconding innovative local pharmacy leaders into central organisations to provide support.

n the Department of health must take account of the role that pharmacy can play when planning initiatives such as the integration transformation fund and the 2014-15 accident and emergency fund.

n nationally and locally, nhs england and its local area teams should convene relevant bodies to support and share pilots of new models of care that involve pharmacy. their goal should be to demonstrate how existing mechanisms such as local pharmaceutical services, enhanced services, any qualified provider, and clinical commissioning group and local government contracts can be used to deliver alternative forms of care.

n nhs england should use its national commissioning role for pharmacy to continue changing the balance of funding from dispensing and supply towards medicines optimisation and the provision of new forms of patient care. this may include the possibility of community pharmacy having separate core contracts for dispensing and supply on the one hand, and for service provision in a broader primary care context on the other.

n there should be openness by nhs england to pharmacists holding these contracts as professionals, perhaps through networks or chambers, rather than through their employers.

n nhs england must be bold in thinking about how pharmacy can form part of any new local population-based contract for primary medical and other care and how the incentives in pharmacy and medical contracts can be aligned. this should include giving full backing to primary care federations, networks and super-partnerships which include pharmacists.

n nhs england’s pharmacy team needs to ensure that pharmacy forms a core part of discussions and plans about integrated patient records, so that pharmacists can be a central part of new models of urgent, out-of-hours and long-term conditions care in particular.

n the Department of health should work with the nhs Leadership academy and nhs england to ensure that pharmacists (and those in the community in particular) have full access to the leadership programmes and resources available to other clinical professions.


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recommendations to local commissioners

n clinical commissioning groups should draw on the potential of pharmacy to improve local services, particularly in response to challenges such as urgent care, out-of-hours primary care, and the need to coordinate care for frail elderly (and other) people living with multiple conditions.

n Local authorities and health and wellbeing boards should study the best examples of provision by pharmacy as they commission public health and social care services. pharmacy has a central role to play in the delivery of safe and high quality care to people in nursing and residential homes, and to those receiving domiciliary social care.

recommendations to the royal pharmaceutical society and leaders of the profession

n the royal pharmaceutical society and other leaders of the profession (and there are many of these) should unite around a clear narrative of the role, purpose and potential of pharmacy.

n the royal pharmaceutical society must raise public and wider nhs and social care awareness of what people should expect from pharmacy, at the same time making the case for a shift in the focus of funding from dispensing and supply to services that support the effective use of medicines and help people stay healthy.

n pharmacists need stronger, more focused professional leadership, nationally and locally. the royal pharmaceutical society should work with other innovative pharmacy leaders to support networks of emerging pharmacy leaders. it should consider drawing together a leaders’ forum made up of those committed to reshaping pharmacy as a care-giving profession of equal status and profile to medicine and nursing.

n the royal pharmaceutical society should accept accountability for moving the profession forward towards a future focused on care delivery, and influencing commissioners and policy makers to enable this. as part of this, it should ask this commission to reconvene in six months, and again in twelve months, to review progress against these recommendations and to report publicly on this.

the royaL pharmaceuticaL societythe royal pharmaceutical society (rps) is the professional body for pharmacists in great Britain.

the royal pharmaceutical society future models of care commission brought together expertise from across health and social care to provide a coherent narrative for the pharmacy profession’s role in the reformed nhs in england.

you can find out more at www.rpharms.com/futuremodels

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NOW OR NEVER - Royal Pharmaceutical Society